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QLDmental health2007-06-20

Eady, Graeme William Julian

25y · Male·hypoxic-ischaemic brain injury due to plastic bag asphyxia

Graeme Eady, 25 years old with chronic depression first formally treated in July 2003, was admitted after a suicide attempt in September 2003. Following an altercation with another patient, he was transferred to H Floor …

psychiatryemergency medicinesystemproceduralsertraline
WAhospital2007-06-08

Inquest into the Death of Rasmussen

31y · Female·cerebral anoxia following attempted intubation pre-surgery in a woman with torti…

Rachael Anne Rasmussen, a 31-year-old mother of three with severe neck deformities (torticollis, dysmorphia, short rigid neck), died on 17 June 2003 from cerebral anoxia following attempted intubation at Joondalup Health…

anaesthesiageneral surgerydiagnosticproceduralatracurium
SAmental health2006-12-21

Coroner's Finding: DOOMA Renato

36y · Male·Multi-organ failure due to consequences of multiple injuries sustained following…

A 36-year-old man with chronic treatment-refractory paranoid schizophrenia was involuntarily detained in an acute psychiatric ward after a failed community trial. Despite being a documented high absconding risk, he was t…

psychiatrytrauma surgerysystemcommunicationzuclopenthixol
NThospital2006-11-10

Inquest into the death of Wendy Walangitj Garmu

45y · Female·hypoxic brain injury following hemopneumothorax resulting from a stab wound to t…

Aboriginal woman stabbed in October 2004, discharged from hospital after initial stab wound assessment without chest X-ray or admission for observation. Wound to posterior chest was explored and stitched by Dr Wal but pn…

emergency medicinesurgerydiagnosticprocedural
SAhospital2006-10-30

Coroner's Finding: GORDON Sally Anne

20y · Female·Cerebral anoxia consequent upon a severe acute asthmatic event

Sally Anne Gordon, a 20-year-old with a 14-year history of severe brittle asthma, presented to Mount Gambier Hospital on 26 November 2000 with acute severe asthma unresponsive to initial treatment. After appropriate emer…

emergency medicineanaesthesiamedicationproceduralsalbutamol
SAhospital2006-09-25

Coroner's Finding: McCARTHY Elly Sarahnia

13y · Female·cerebral oedema and infarction secondary to extensive subdural empyema

Elly McCarthy, a 13-year-old girl, died from cerebral oedema and infarction secondary to subdural empyema. She developed fever, headache and neurological symptoms on 24 January 2004 and was initially seen at a GP and Noa…

paediatricsemergency medicinediagnosticcommunicationtrimethoprim
SAhospital2006-05-19

Coroner's Finding: FALANGA Salvatore

77y · Male·complications of haemothorax and hypotension following drainage of pleural effus…

77-year-old male died from complications of haemothorax and hypotension following drainage of pleural effusion post-coronary bypass surgery, in the setting of pre-existing renal impairment and diabetes. During pleural ta…

cardiologycardiothoracic surgerydiagnosticproceduralramipril
SAhospital2006-05-18

Coroner's Finding: PAHL-CADMAN Emma Rose

20y · Female·cardiac dysrhythmia/arrest in a 20 year old Down's Syndrome female following abd…

A 20-year-old woman with Down syndrome and Eisenmenger syndrome (cyanotic heart disease with ventricular septal defect) was admitted with abdominal obstruction. After appropriate diagnostic workup, laparotomy was perform…

general surgeryanaesthesiadiagnosticcommunication
NTcommunity2006-05-04

Inquest into the death of Cynthia Diane Ching

29y · Female·multiple organ failure following persistent sepsis occurring as a complication o…

Cynthia Diane Ching, a 29-year-old Canadian visitor, sustained severe burns (60% of body) on 15 April 2004 when aviation fuel from a makeshift lantern was spilled onto her by one of two helicopter pilots at Kings Creek S…

plastic and reconstructive surgeryintensive careproceduralsystemmorphine
SAhospital2005-11-15

Coroner's Finding: DAMIANOU Dimitra

79y · Female·cardio-respiratory arrest consequent upon the aspiration of food

A 79-year-old woman with post-stroke dysphagia died from aspiration of food while hospitalised. A speech pathologist prescribed a minced diet after an unsuccessful soft diet trial, but the patient received a soft diet me…

speech pathologyneurologycommunicationsystem
SAhospital2005-06-02

Coroner's Finding: HUTCHINSON Matthew

0y · Male·cardiogenic shock and neonatal encephalopathy

Matthew Hutchinson, born at 1 day of age at Flinders Medical Centre, died from cardiogenic shock and neonatal encephalopathy. While obstetric care was appropriate, neonatal care was significantly deficient. Critical fail…

neonatologyobstetricsproceduralcommunicationphenobarbital
SAhospital2005-01-18

Coroner's Finding: SQUIRES Dorothy Alberta

90y · Female·incompatible blood transfusion resulting in haemolysis and multi-organ failure c…

A 90-year-old woman with acute myocardial infarction and cardiogenic shock died after receiving an incompatible blood transfusion (A- instead of O+), which caused haemolysis and multi-organ failure. The registered nurse …

cardiologyintensive careproceduralcommunication
NTcommunity2004-12-14

Inquest into the death of Nikita Anderson

0y · Female·bronchopneumonia caused by hypoxic brain damage caused or contributed to by meni…

A 9-month-old Aboriginal girl died from bronchopneumonia caused by hypoxic brain damage following cardiorespiratory arrest due to meningitis and seizures. During resuscitation at a rural GP clinic, a CO₂ cylinder was ina…

general practicepaediatricsproceduralsystemadrenaline
WAhospital2004-07-19

Inquest into the Death of Michael John Herrick

44y · Male·cardiac arrhythmia in a man with liver failure due to cirrhosis and focal corona…

Michael John Herrick, a 44-year-old prisoner with end-stage liver cirrhosis secondary to hepatitis C and alcohol abuse, died from cardiac arrhythmia at Sir Charles Gairdner Hospital. He had been receiving aggressive trea…

gastroenterologygeneral medicinecommunicationproceduralcaffeine
WAhospital2004-06-17

Inquest into the Death of Edmiston

41y · Female·Peritonitis following surgical procedure to the urinary bladder, due to infected…

Cheryl Lee Edmiston, a healthy 41-year-old woman, died of peritonitis and sepsis following minor bladder procedures (cystoscopy, hydrodilatation, and biopsy) at Joondalup Health Campus on 14 February 2003. The biopsies w…

urologygeneral surgerydiagnosticmedicationamoxicillin
WAhospital2003-08

Inquest into the Death of Richard Christopher Jankowski

39y · Male·Hypoxic brain injury due to respiratory obstruction following surgery for dental…

Richard Christopher Jankowski, a 39-year-old man, died from hypoxic brain injury due to respiratory obstruction following emergency surgery for a dental abscess with cellulitis. After initial treatment with antibiotics, …

anaesthesiageneral surgeryproceduralcommunicationpropofol
SAhospital2001-05-04

Coroner's Finding: ROACH Dawn Ruth

45y · Female·Multi-organ failure due to septicaemia and peritonitis due to faecal leakage fro…

A 45-year-old woman died from multi-organ failure following failure of a loop colostomy created for management of an anastomotic leak after bowel cancer surgery. The initial anastomotic leak (1.5 cm) was contained and re…

colorectal surgerygeneral surgeryproceduralcommunication
WAcommunity2000-05-18

Inquest into the Death of Syoko Tsubaki

24y · Female·Immersion (drowning due to hypoxic brain injury)

Syoko Tsubaki, a 24-year-old Japanese tourist and inexperienced recreational diver, died from drowning on 31 December 1998 after a scuba diving incident at Rottnest Island on 27 December. During an afternoon dive, the di…

diving medicineemergency medicinecommunicationprocedural

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